§ 31–3101. Definitions.

For the purposes of this chapter, the term:

(1) “Alcohol abuse” means any pattern of pathological use of alcohol that causes impairment in social or occupational functioning, or that produces physiological dependency evidenced by physical tolerance or by physical symptoms when it is withdrawn.

(1A) “Advanced practice registered nurse” means a person licensed as a registered nurse and certified as an advanced practice registered nurse pursuant to the District of Columbia Health Occupations Revisions Act of 1985 Amendment Act of 1994 or by the state or territory where the person practices as an advanced practice registered nurse.

(2) “Clinically significant” means sufficient to impair substantially a person’s judgment, behavior, capacity to recognize, or ability to cope with the ordinary demands of life.

(2A) “Commissioner” means the Commissioner of the Department of Insurance, Securities, and Banking.

(3) “Council” means the Council of the District of Columbia.

(4) “Covered benefits” means the health-care services or treatment available to:

(A) An insured party under a health benefits plan or certificate for which the health insurer will pay part or all of the cost;, or

(B) A member of a health maintenance organization as part of the membership contract.

(5) “District” means the District of Columbia.

(6) “Drug abuse” means any pattern of pathological use of a drug that causes impairment in social or occupational functioning, or that produces physiological dependency evidenced by physical tolerance or by physical symptoms when it is withdrawn.

(6A) “Health benefits plan” means any accident and health insurance policy or certificate, hospital and medical services corporation contract, health maintenance organization subscriber contract, plan provided by another benefit arrangement. The term “health benefit plan” does not mean accident only, credit, or disability insurance; coverage of Medicare services or federal employee health plans, pursuant to contracts with the United States government; Medicare supplemental or long-term care insurance; dental only or vision only insurance; specified disease insurance; hospital confinement indemnity coverage; limited benefit health coverage; coverage issued as a supplement to liability insurance, insurance arising out of a workers’ compensation or similar law; automobile medical payment insurance; medical expense and loss of income benefits; or insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.

(6B) “Health insurer” means any person that provides one or more health benefit plans or insurance in the District of Columbia, including an insurer, a hospital and medical services corporation, a fraternal benefit society, a health maintenance organization, a multiple employer welfare arrangement, or any other person providing a plan of health insurance subject to the authority of the Commissioner.

(7) “Health maintenance organization” or “HMO” means any person that undertakes to provide or arrange for the delivery of basic health care services to enrollees on a prepaid basis, except for enrollees responsibility for co-payments and deductibles, and qualifies as a health maintenance organization under Chapter 34 of Title 31.

(8) “Hospital” means a facility licensed as a hospital by the District or by any state or territory of the United States or operated by the District, any state or territory, or the United States.

(8A) “Individual market” means the market for health insurance coverage offered to individuals other than in connection with a group health plan.

(9) “Inpatient services” means therapeutic services that are medically or psychologically necessary and that are provided in a hospital or a nonhospital residential facility to patients admitted to the hospital or nonhospital residential facility.

(10) Repealed.

(10A)(A)(i) Except as provided in sub-subparagraph (ii) of this subparagraph, “large employer” means, in connection with a group health plan with respect to a calendar year and a plan year, a single employer that employed an average of at least 51 employees on business days during the preceding calendar year and at least 2 employees on the first day of the plan year.

(ii) Beginning in calendar year 2016 and for each succeeding year, “large employer” means, in connection with a group health plan with respect to a calendar year and a plan year, a single employer that employed an average of at least 101 employees on business days during the preceding calendar year and at least 2 employees on the first day of the plan year.

(B) For the purposes of this paragraph:

(i) All persons treated as a single employer under section 414(b), (c), (m), or (o) of the Internal Revenue Code of 1986, approved October 22, 1986 (100 Stat. 2085; 26 U.S.C. § 414(b), (c), (m), or (o)), shall be treated as a single employer;

(ii) An employer and any predecessor employer shall be treated as a single employer;

(iii) All employees shall be counted, including part-time employees and employees who are not eligible for health benefit coverage through the employer; and

(iv) If an employer was not in existence throughout the preceding calendar year, the determination of whether that employer is a large employer shall be based on the average number of employees that the employer is reasonably expected to employ in the current calendar year.

(10B) “Large group market” means the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves and their dependents through a group health plan maintained by a large employer.

(10C) “Managed care system” means a method that a health insurer uses to review and preauthorize a treatment plan that a health care practitioner develops for a covered person using a variety of cost containment methods to control utilization, quality and claims.

(11) “Mayor” means the Mayor of the District of Columbia.

(11A) “Medical or surgical benefits” means benefits with respect to medical or surgical services as defined under the terms of the plan or coverage, but does not include mental health benefits.

(12) “Medically or psychologically necessary” means essential for the treatment of drug abuse, alcohol abuse, or mental illness, as determined by a physician, psychologist, or social worker.

(12A) “Mental health benefits” means benefits with respect to mental health services, as defined under the terms of the plan or coverage, but does not include benefits with respect to treatment of substance abuse or chemical dependency.

(13) “Mental illness” means any psychiatric disease identified in the most recent edition of the International Classification of Diseases or of the American Psychiatric Association Diagnostic and Statistical Manual.

(14) “Nonhospital residential facility” means a facility certified by the District or by any state or territory of the United States as a qualified nonhospital provider of treatment for drug abuse, alcohol abuse, mental illness, or any combination of these, in a residential setting. The term “nonhospital residential facility” includes any facility operated by the District, any state or territory, or the United States to provide these services in a residential setting.

(15) “Outpatient services” means therapeutic services that are medically or psychologically necessary and that are provided to a patient according to an individualized treatment plan that does not require the patient’s admission to a hospital or a nonhospital residential facility. The term “outpatient services” refers to services that may be provided in a hospital, a nonhospital residential facility, an outpatient treatment facility, or the office of a licensed physician, psychologist, or social worker.

(16) “Outpatient treatment facility” means a clinic, counseling center, or other similar location that is certified by the District or by any state or territory as a qualified provider of outpatient services for the treatment of drug abuse, alcohol abuse, or mental illness. The term “outpatient treatment facility” includes any facility operated by the District, any state or territory, or the United States to provide these services on an outpatient basis.

(17) “Peer review” means a system based on written procedures and formally established within the professions of medicine or any of its specialties, psychology, or social work in which a committee of licensed practitioners of the profession reviews another practitioner’s diagnosis and treatment in a specific case and reaches conclusions and recommendations concerning the accuracy of the diagnosis, and the necessity, appropriateness, and effectiveness of the treatment provided and proposed by the practitioner compared to alternative treatments. For the purposes of § 31-3110, the term “peer review” shall also mean the professional utilization procedure or any similar procedure employed by health maintenance organizations.

(18) “Physician” means a person licensed to practice medicine by the District pursuant to the District of Columbia Health Occupations Revision Act of 1985 or by the state or territory where the person practices medicine.

(19) “Psychologist” means a person licensed to practice psychology by the District pursuant to the District of Columbia Health Occupations Revision Act of 1985 or by the state or territory where the person practices psychology.

(19A)(A)(i) Except as provided in sub-subparagraph (ii) of this subparagraph, “small employer” means a single employer that employed an average of not more than 50 employees during the preceding calendar year.

(ii) Beginning in calendar year 2016 and for each succeeding year, “small employer” means a single employer that employed an average of not more than 100 employees during the preceding calendar year.

(B) For the purposes of this paragraph:

(ii) An employer and any predecessor employer shall be treated as a single employer;

(iii) All employees shall be counted, including part-time employees and employees who are not eligible for health benefit coverage through the employer;

(iv) If an employer was not in existence throughout the preceding calendar year, the determination of whether that employer is a small employer shall be based on the average number of employees that the employer is reasonably expected to employ in the current calendar year.

(19B) “Small group market” means the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves and their dependents through a group health plan maintained by a small employer.

(20) “Social worker” means a person licensed as an independent clinical social worker by the District pursuant to § 3-1208.04, or who is licensed to practice social work with authority to engage in the independent practice of psychotherapy by the state or territory where the person practices social work.

(21) Repealed.

(22) “Supplemental benefit” means health insurance coverage provided by the District to its employees in addition to the coverage provided through the Federal Employees Health Benefits Plan pursuant to § 1-621.01.

(Feb. 28, 1987, D.C. Law 6-195, § 2, 34 DCR 491; Mar. 23, 1995, D.C. Law 10-247, § 3, 42 DCR 457; May 21, 1997, D.C. Law 11-268, § 10(w), 44 DCR 1730; Mar. 24, 1998, D.C. Law 12-81, § 33, 45 DCR 745; Oct. 21, 2000, D.C. Law 13-178, § 2(a), 47 DCR 6844; June 18, 2003, D.C. Law 14-312, § 501, 50 DCR 306; June 11, 2004, D.C. Law 15-166, § 4(r), 51 DCR 2817; Mar. 8, 2007, D.C. Law 16-242, § 2(a), 54 DCR 601; May 2, 2015, D.C. Law 20-265, § 102, 62 DCR 1529.)

Prior Codifications

1981 Ed., § 35-2301.

Effect of Amendments

D.C. Law 13-178 added definitions contained in pars. (8A), (10A), (11A), (12A), (19A) and (19B).

D.C. Law 14-312 rewrote par. (7) which had read as follows: “(7) ‘Health maintenance organization’ means a public or private organization that is a qualifying health maintenance organization under federal regulations, or has been determined to be a health maintenance organization pursuant to regulations adopted by the State Health Planning and Development Agency of the District.”

D.C. Law 15-166, in par. (2A), substituted “Commissioner of the Department of Insurance, Securities, and Banking” for “Commissioner of Insurance and Securities”.

D.C. Law 16-242 rewrote par. (4); added pars. (6A), (6B), and (10C); and repealed par. (10).

The 2015 amendment by D.C. Law 20-265 rewrote (10A) and (19A).

Emergency Legislation

For temporary amendment of section, see § 2(a) of the Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage Emergency Amendment Act of 1998 (D.C. Act 12-274, February 19, 1998, 45 DCR 1526), and § 2(a) of the Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage Second Emergency Amendment Act of 1998 (D.C. Act 12-546, December 18, 1998, 46 DCR 497).

For temporary amendment of section see § 6(a) of the Vendor Payment and Drug Abuse, Alcohol Abuse, and Mental Illness Coverage Emergency Amendment Act of 1998 (D.C. Act 12-396, Sept. 16, 1998, 45 DCR 6952).

For temporary (90 day) amendment of section, see § 4(r) of Consolidation of Financial Services Emergency Amendment Act of 2004 (D.C. Act 15-381, February 27, 2004, 51 DCR 2653).

Temporary Legislation

For temporary (225 day) amendment of section, see § 2(a) of Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage Temporary Amendment Act of 1998 (D.C. Law 12-108, May 8, 1998, law notification 45 DCR 3259).

For temporary (225 day) amendment of section, see §§ 2 to 4 of the Vendor Payment and Drug Abuse, Alcohol Abuse, and Mental Illness Coverage Temporary Act of 1998 (D.C. Law 12-181, March 26, 1999, law notification 46 DCR 3407).

References in Text

The “District of Columbia Health Occupations Revision Act of 1985,” referred to in paragraphs (18) and (19), is D.C. Law 6-99.

The “District of Columbia Health Occupations Revision Act of 1985 Amendment Act of 1994,” referred to in (1A), is D.C. Law 10-247, which is codified primarily throughout Title 3, Chapter 12.

Editor's Notes

Department of Insurance abolished: The Department of Insurance, including the Superintendent, was abolished and the functions thereof transferred to the Board of Commissioners of the District of Columbia by Reorganization Plan No. 5 of 1952. Reorganization Order No. 43, dated June 23, 1953, as amended, established, under the direction and control of a Commissioner, a Department of Insurance headed by a Superintendent. The Order provided for the organization of the Department, abolished the previously existing Department of Insurance, and provided that all functions and positions of the previous Department would be transferred to the new Department of Insurance, including the duties, powers, and authorities of all officers and employees; and that all personnel, property, records and unexpended balances relating to the functions and positions transferred would also be transferred to the new Department. The executive functions of the Board of Commissioners were transferred to the Commissioner of the District of Columbia by § 401 of Reorganization Plan No. 3 of 1967. The functions of the Superintendent of Insurance were transferred to the Department of Consumer and Regulatory Affairs by Reorganization Plan No. 1 of 1983, effective March 31, 1983. Pursuant to the provisions of D.C. Law 11-268, the Department of Insurance and Securities Regulation was established and the duties of the Superintendent of Insurance and the Insurance Administration were assumed by the Commissioner of Insurance and Securities, and the Insurance Administration in the Department of Consumer and Regulatory Affairs was abolished.